Dr Puneet Seth from the Department of Emergency Medicine at SengKang Health explains how the Comfort Care Protocol is implemented as part of palliative care​ in Singapore General Hospital's​ ​(SGH) ​A&E.

​is the next ​step in end-of-life care, where discharged patients have their conditions eased at the A&E bef​

Everyone deserves dignity and comfort in their final moments. But when those moments happen in a hospital’s Accident and Emergency Department (A&E), how can such patients be assured of the care and comfort they rightly need?

That question has become more urgent as emergency departments receive more and more end-stage disease patients who have run out of treatment options. Their families may understand and accept that the last moments of their loved ones are inevitable and near. Yet, when confronted with the extreme pain and other symptoms that their loved ones suffer, these families will inevitably turn to hospitals’ A&Es.

To be sure, such patients will be given emergency care. But more than that, they will need to be given relief from pain and stress when it has been established that nothing further can be done for them. Such care may seem to be at odds with the image of the typical A&E – a high-octane activity arena where emergency procedures are carried out in an effort to save life-threatening cases, where speed is paramount, and where horrific traffic accident injuries and cardiac arrest cases jostle for the attention of doctors and nurses.

Comfort Care Protocol in the A&E - more than just emergency care

Yet, in emergency departments around the world, a gentler patient-centric approach to care has been quietly gathering pace. It is no different at the
Singapore General Hospital​ (SGH), where emergency medicine staff began implementing what we call the Comfort Care Protocol in December 2014. This is a checklist that attending doctors go through to ensure the hospital does everything possible to make a patient and his family comfortable. (The protocol was put together by a multidisciplinary team including nurses and social workers, with the help of
Dr Grace Yang​, Consultant, Division of
Palliative Medicine​,
National Cancer Centre Singapore​.)

Is the patient feeling nauseous? Is he feeling breathless because fluid has accumulated in his lungs? Has he soiled his clothes? Is he feeling dirty or does he smell stale? Many patients who come to us at the A&E suffer from advanced stage cancer or organ failure, so a question as seemingly trivial as whether he is lying down comfortably is included in the checklist. This is because patients suffering from some cancers may not be able to lie down in normal positions. So it is important that our staff be alert to this possibility and ask that question.

At such times, too, families will want to spend as much time as possible with their loved ones. They will also want privacy. In that regard, we will try to get them a room quickly, away from the main emergency area. With the protocol in place, a bed can now be secured much more quickly. Indeed, since the protocol was adopted, I am proud to say that none of the patients who are deemed to need end-of-life care have waited for more than three hours. These may seem like simple, everyday tasks that one often takes for granted. But in the busy, often chaotic, environment of the emergency department, they can be easily overlooked. We may know that these patients no longer respond to treatment, but we want to – and can – give them basic care, be it for something like low blood sugar or a simple infection. Looking after his wounds may not prolong his life or reverse his condition, but he will at least feel better.

Before we started the Comfort Care Protocol, there was the problem of providing what we felt was incomplete care. For instance, patients might be given oxygen to help them breathe. But their pain may not be attended to as quickly simply because we were not tuned to look for it. Knowing we did our best and that we didn’t overlook even the smallest thing doesn’t just comfort our patients and their families. Indeed, the emergency team’s response to the protocol has been positive. Our staff said they felt good having a checklist to follow to avoid missing out on doing right by our patients. As health care professionals committed to looking after the sick, we don’t want to realise too late that we could have done something but didn’t. A seemingly small thing like not providing pain relief can stay on our minds for a long time. In time, such feelings of regret will fade. Not so for the family members. They are likely to experience again and again the anguish they felt seeing how their father, mother, child or sibling suffered great pain in their last hours.

As health care professionals in the emergency department, our mindset has been geared towards treating the sick and the injured, not so much on addressing the dying. But there is much that we can do as this protocol has shown. Terminal discharge is the next step in end-of-life care. This involves the discharge of patients whose condition has improved after pain and other immediate problems have been eased at the A&E so that they can breathe their last at home.

Most people would prefer to die in familiar surroundings rather than in a hospital. For this to work, we will need to determine what patients might need – such as oxygen cylinders, painkillers or other supplies – so that back home, they can receive the same kind of care that hospitals provide. It is hard to predict the number of days or hours a patient has left. The fact that it is not an exact science makes it challenging but also very rewarding – rewarding because it intertwines medicine with human feelings.

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